The Pernicious Politics of the DSM-V

A brilliant look at the medicalization of misery

May 8, 2013

Back in the benighted old days of the DSM-III—the third iteration of the Diagnostic and Statistical Manual, the American Psychiatric Association’s official catalog of the mental illnesses—my therapy patients included a 26-year-old man who came to see me due to his wife’s complaint that he’d “gotten out of control of himself.” The attractive couple had recently been united for life in a grand ceremony in her hometown, followed by an even splashier party on the highest floor of the Prudential Tower in Boston. He was a commercial real estate agent, a rising star, and she was in law school.

The wife accompanied her new husband and explained to me, “We had the perfect relationship, but now he doesn’t even sleep with me. Actually, he doesn’t sleep at all. And he talks so fast I can’t understand him sometimes. And he’s mean! He was never like that before.” At this, he jumped up and began to pace. “She’s an idiot, right?” he barked. “The last thing I am is out of control! I’m going to sell the damn Prudential building, you know? What the hell are we doing here?”

I began to deduce what the pitiless fates surely knew, that this young man was not going to broker the Pru. He was probably not even going to hold on to his job, or for that matter, his pretty wife, who was already exhibiting the frightened expression and roving gaze of someone looking for a way out. I worried that a psychiatric label might shove her from the warmth of concern into the chilly detachment of self-preservation. But they insisted on a formal evaluation, and I referred them to a colleague who specializes in diagnostics and psychopharmacology. The verdict came back “Bipolar Disorder.”1

After the diagnosis, the husband came to his next therapy session alone and literally dropped to his knees, his hands clasped before him: “I’m begging you—take it back. I want a different diagnosis. Please, please say this one is wrong! Please make it go away!”

But naming something makes it real, and psychiatric nomenclature includes some of the nastiest pejoratives humans have ever uttered. The labels can be catastrophic when they are wrong and sometimes worse when they are right. In either case, they almost never go away to leave a life in peace. Whenever I’ve had occasion to write a diagnosis code on a health insurance form, in my mind’s eye I still see that young man kneeling on my office floor, pleading, and I’ve used that memory to keep myself awake to the identity-wrenching impact of psychiatric nomenclature. Would my patient have been better off without the label and therefore without the opportunity—the mandate, even—to be treated (with drugs, of course)? Or would I have been better advised to work with his spouse’s straightforward and cheap-to-run assessment that he was “out of control of himself”?

In The Book of Woe: The DSM and the Unmaking of Psychiatry, psychotherapist and author/journalist Gary Greenberg contends that the politics behind the label-making have become so dense and so pernicious, and the science so thin, that the answer to both questions may very well be yes.2 Greenberg is not the first to make such an argument, but he makes it with extraordinary eloquence and with the insight of a true insider. For more than two years, he embedded himself in the labors of the American Psychiatric Association (APA) as it rewrote—for the fifth time—its Diagnostic and Statistical Manual, psychiatry’s nosological bible. The Book of Woe is his account of the making of the DSM-5.

The history of the DSM process, according to Greenberg, is one of increasing secrecy, attempts to be politically correct (to avoid reminding the public of the “sexual reorientation therapy” scandal that occurred when homosexuality was still tagged as a disorder), and the APA’s “aspirational relationship to modern medicine.” He provides a ringside perspective on the power struggles that surround the DSM: the cringe-making turf wars inside the APA, its ongoing competitions with the World Health Organization and the American Psychological Association, and allegations from more philosophical quarters that the DSM’s definition of disease is designed “to maintain physician dominion over mental suffering.” (The APA stands accused of attempting to include under the purview of psychiatry many of the natural and normal forms of suffering, such that doctors may diagnose more illnesses and prescribe more medications—drugs that act in poorly understood ways and that typically have a long list of grim side effects. This criticism is especially alarming when leveled at the “discovery” and treatment of childhood disorders.) He reveals why and how the APA reinvented the statistical bar for concluding that a diagnosis is reliable across diagnosticians, removed from its compendium the relatively clear and familiar diagnosis of Asperger’s Syndrome, and added entirely new and especially controversial diagnoses such as “Disruptive Mood Dysregulation Disorder.”

Psychiatric nomenclature includes some of the nastiest pejoratives humans have ever uttered.

Greenberg is not evenhanded or equable in recounting all this. He is clear in his convictions, scathing, and repeatedly in your face, or rather in the faces of the mental health professionals he follows, verbally sketches, interviews, and (somewhat ironically) assesses. By a different author, a book with a similar outlook might have been full-on shrill. But Greenberg is an exceptional writer, and his book is deft and persuasive, and, despite its essentially unhappy topic, it made me laugh out loud on more than one occasion.

Indeed, The Book of Woe is delicious, in that it dishes generously on the DSMs and on psychiatry in general. An appetitive metaphor, even a carnivorous one, works well here, since Greenberg demonstrates with the force of an all-in journalist that the APA has not ever, to use his recurring figure of speech, “carved the mind at its joints,” and he lays bare this embarrassing fact by slicing up the DSM process: the of-a-certain-era nature of certain psychiatric diagnoses (e.g., homosexuality), the credibility problem engendered by frequent revisions (akin to continual revisions of the Bible), and the disorders that come and go “with dismaying regularity.” And he brings his readers up to speed on some of the more complex sources of mistrust: improbably drastic shifts in prevalence rates based on psychiatric labels and the use of a categorical approach to diagnosis that fails to represent the reality of mental illness.

Individual psychiatrists are royally served up, as well. Former APA medical director Steve Mirin assures Greenberg that “coming down the mountain with the Ten Commandments sure sells a lot of books.” And Massachusetts General Hospital’s Joseph Biederman, initiator of the “child bipolar” epidemic that began in the 1980s, had the following exchange with a lawyer, after Biederman’s testimony at a sworn deposition that he was a full professor at Harvard: "Lawyer: What’s after that? Biederman: God. Lawyer: Did you say God? Biederman: Yeah."

There are at least three good reasons to read The Book of Woe. First, most of us—mental health professionals definitely included—do not fully appreciate the degree of influence the Diagnostic and Statistical Manual has had and still has. Greenberg owns as commonplace what I think many clinicians fear is an atypical guilty secret: that we use a diagnostic system we don’t respect to bill insurance companies for our patients. He writes, “I know therapists who diagnose everyone with Adjustment Disorder unless the insurance company limits benefits for its treatment … at which point the patient often contracts a sudden case of something much worse, like Major Depressive Disorder.”

But more broadly than this, the DSM profoundly influences nothing less than humankind’s beliefs about itself. The DSM tells people all over the world how to figure out who is normal and who is not, and there are few questions by which human beings are quite so universally intrigued. A woman who is “too angry”—is she afflicted with a personality disorder? Possibly. How self-centered can you be before you merit a psychiatric label? It depends. At what point, if any, can the emotional intensity of childhood be deemed “psychotic risk,” or “anxiety,” or “hypomania”? Under discussion. Can certain little children be called conscienceless? Probably.

Wikimedia Commons

DIAGNOSING PROBLEMS

Samuel A. Cartwright, the nineteenth-century physician who coined the term drapetomania, or "the disease causing Negroes to run away" from their owners.

Second, in view of the wide and deep influence of the DSM, it is unnerving, and very useful, to be reminded that psychiatric diagnoses are not only in flux—morphing, coming and going, rising and falling in popularity—they are also subject to immeasurably destructive cultural beliefs and bigotry. The word hysteria refers to a “wandering uterus.” A person diagnosed with “Borderline Personality Disorder”—a condition characterized in part by “persistent or frequent angry feelings”—is much more likely to be a woman than a man. As Greenberg points out on the very first page, a physician in Louisiana was intent, in 1850, on coining a new disorder: drapetomania, the “disease causing Negroes to run away” from slavery. And, until recently, sexual orientation was either right or it was sick.

Third—and this one is an “oh yeah, of course” revelation—we almost never ponder the fact that the APA’s publishing arm, American Psychiatric Publishing, Inc., is a business. Without reading The Book of Woe, one might never come across the startling fact that, from sales of the DSM-IV alone, this business raked in a hundred million dollars. (The price of the new DSM-5 volume, available later this month, is $199.) As Greenberg asserts, “If the story of the DSM-5 has any redeeming value, if it is more than a story about parochial disputes and internecine warfare, it is that it can reveal the conditions that motivate the publication of the DSM and the interests that another revision serves.”

The Book of Woe is ultimately the story of how a group of brainy and experienced people, charged with near-paranoid secrecy, disguised, even from themselves, the fact that they were not proceeding scientifically, and how they emerged with a document intended to parse human suffering into natural categories that human suffering does not have. To complete this assignment, they included more or less plausible categories from their imaginations and their experience and also from reality’s vast store of normal suffering. (The assimilated normal reactions range from grief after the death of a loved one to a craving for too much time online: “Internet Use Disorder,” relegated at the last minute to the appendix of DSM-5.) The story contains the breathtaking subplot that the document they manufactured will touch, in one way or another, most of the human lives on the planet. Also, for the creators and a few other select groups, this single volume will make a great deal of money.

Sales of the DSM-IV alone raked in a hundred million dollars.

The one problem with this convincing and disturbing account is that, in his enthusiastic focus on the bad behavior of the APA, Greenberg risks losing sight of the fact that the field of mental health truly needs some agreed-upon descriptive labels for certain psychological aberrancies, and the interest and the funding and the time to study them properly. (This is very different from saying we need a book that claims to include all possible disorders of the mind. Such a “need” is perhaps less a desire to understand and help, and more an impossible lust for complete mastery.) In the last chapter of his book, Greenberg offers a lengthy and seductive analysis of whether or not his book is a product of “anti-psychiatry.” He thinks it is not, and assures us that he does not blame psychiatrists, since “they are in the grips of forces bigger than they are.” This anti-psychiatry-or-not discussion is probably unnecessary. Worse, it distracts from what is perhaps the most regrettable aspect of the DSM’s failure—that clinicians need clearly articulated concepts, a common language, and that productive, interpretable, replicable research requires this vocabulary, too. Still, Greenberg is better than any other critic I have seen at explaining why the love of money and power may never allow us to admit that the study of the mind is different from the investigation of the brain, and that the former is many more parts philosophy than neurology—and why it is only such an admission that would allow us to work toward genuinely helpful (if not perfectly unitary and complete) descriptive systems.

Greenberg sets out to reveal that psychiatry has never successfully carved nature at its joints. He makes an entirely cogent and, along the way, darkly entertaining case. He demonstrates also that both the prestigious position and financial viability of psychiatry as a profession are increasingly dependent on its alchemistic transformation of normal human suffering into various arcane “illnesses.” For these reasons alone, his book is an essential eye-opener for most people interested in the “mental disorders” and for all of us who practice the treatment of them. But perhaps the most important lesson to be found in the Book of Woe is that a mighty scientific endeavor to sort reality from superstition and prejudice, one with an unfathomable cultural influence on the twentieth century—and likely the twenty-first as well—has been (perhaps terminally) commercialized by an all-too-real desire for superordinate power and adequate financing.

This was according to the DSM-III, which, in 1980, had nixed the name “Manic-Depressive Disorder,” but still had not divided the malady into the “Bipolar I” and “Bipolar II” forms that would be described in 1994 by DSM-IV (distinguished primarily by whether the patient experiences mania or hypomania).

In fact, the National Institute of Mental Health is so dissatisfied with the American Psychiatric Association’s approach to classifying mental illnesses that NIMH is moving away from relying on the DSM and looking to "to transform diagnosis by incorporating genetics, imaging, cognitive science and other levels of information to lay the foundation for a new classification system."